Treatment guideline reduces hypoglycemic events in critically ill children
Children may develop stress hyperglycemia (elevated blood-glucose levels) during critical illness. Strict blood-sugar control in critically ill children may impact outcome. However, this strategy increases the risk of hypoglycemia (low blood glucose). In adults the occurrence of hypoglycemia has been shown to be an independent risk factor for mortality. Recently, a major children's hospital developed a guideline for the initiation and maintenance of insulin infusions for stress hyperglycemia in the pediatric intensive care unit. Hypoglycemic events declined significantly after the guideline's implementation.
A quality improvement team of physicians in critical care medicine and endocrinology developed and implemented the guideline. Other team members included a pharmacist, a quality improvement consultant, a patient safety officer, and a project manager. The guideline consisted of an algorithm to determine an initial dose of insulin, instructions on how to adjust and then discontinue the infusions, and recommendations for bedside blood-glucose monitoring. The guideline was released as an order set in the hospital's computerized clinical order entry system. A hard copy was also placed in every chart.
Hypoglycemic events dropped dramatically from 36 percent before guideline implementation to 12 percent after implementation, despite an increase in the total number of patient days on insulin infusion. After 2 years, the incidence of these events dropped further to 3 percent. Additionally, the average number of days between hypoglycemic events lengthened from 21 to 186 days. These successful outcomes were due to greater provider adherence to glucose checks as suggested by the guideline. The study was supported in part by the Agency for Healthcare Research and Quality (HS16957).
See "Reduction in hypoglycemic events in critically ill patients on continuous insulin following implementation of a treatment guideline," by Ranjit S. Chima, M.D., Pamela J. Schoettker, M.S., Kartik R. Varadarajan, M.P.H., and others in the January-March 2012 Quality Management in Health Care 21(1), pp. 20-28.
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